Risk factors for recurrence of acute gastrointestinal bleeding from angiodysplasia

Nationwide cohort study identifies clinical outcomes of angioectasia in patients with acute hematochezia

BACKGROUND

While angioectasia is an important cause of acute hematochezia, relevant clinical features remain unclear. This study aims to reveal risk factors, clinical outcomes, and the effectiveness of therapeutic endoscopy for patients with acute hematochezia due to angioectasia.

METHODS

This retrospective cohort study was conducted at 49 Japanese hospitals between January 2010 and December 2019, enrolling patients hospitalized for acute hematochezia (CODE BLUE-J study). Baseline factors and clinical outcomes for angioectasia were analyzed.

RESULTS

Among 10,342 patients with acute hematochezia, 129 patients (1.2%) were diagnosed with angioectasia by colonoscopy. The following factors were significantly associated with angioectasia: chronic kidney disease, liver disease, female, body mass index < 25, and anticoagulant use. Patients with angioectasia were at a significant increased risk of blood transfusions compared to those without angioectasia (odds ratio [OR] 2.61; 95% confidence interval [CI] 1.69-4.02). Among patients with angioectasia, 36 patients (28%) experienced rebleeding during 1-year follow-up. The 1-year cumulative rebleeding rates were 37.0% in the endoscopic clipping group, 14.3% in the coagulation group, and 32.8% in the conservative management group. Compared to conservative management, coagulation therapy significantly reduced rebleeding risk (P = 0.038), while clipping did not (P = 0.81). Multivariate analysis showed coagulation therapy was an independent factor for reducing rebleeding risk (hazard ratio [HR] 0.40; 95% CI 0.16-0.96).

CONCLUSIONS

Our data showed patients with angioectasia had a greater comorbidity burden and needed more blood transfusions in comparison with those without angioectasia. To reduce rebleeding risk, coagulation therapy can be superior for controlling hematochezia secondary to angioectasia.

A Review of Colonoscopy in Intestinal Diseases

Since the development of the fiberoptic colonoscope in the late 1960s, colonoscopy has been a useful tool to diagnose and treat various intestinal diseases. This article reviews the clinical use of colonoscopy for various intestinal diseases based on present and future perspectives. Intestinal diseases include infectious diseases, inflammatory bowel disease (IBD), neoplasms, functional bowel disorders, and others. In cases of infectious diseases, colonoscopy is helpful in making the differential diagnosis, revealing endoscopic gross findings, and obtaining the specimens for pathology. Additionally, colonoscopy provides clues for distinguishing between infectious disease and IBD, and aids in the post-treatment monitoring of IBD. Colonoscopy is essential for the diagnosis of neoplasms that are diagnosed through only pathological confirmation. At present, malignant tumors are commonly being treated using endoscopy because of the advancement of endoscopic resection procedures. Moreover, the characteristics of tumors can be described in more detail by image-enhanced endoscopy and magnifying endoscopy. Colonoscopy can be helpful for the endoscopic decompression of colonic volvulus in large bowel obstruction, balloon dilatation as a treatment for benign stricture, and colon stenting as a treatment for malignant obstruction. In the diagnosis of functional bowel disorder, colonoscopy is used to investigate other organic causes of the symptom.

Heart Team for Left Appendage Occlusion without the Use of Antithrombotic Therapy: The Epicardial Perspective

Background: Left atrial appendage occlusion is an increasingly proposed treatment for patients with atrial fibrillation and poor tolerance to anticoagulants. All endovascular devices require antithrombotic therapy. Anatomical and clinical variables predisposing to device-related thrombosis, as well as post-procedural peri-device leaks, could mandate the continuation or reintroduction of aggressive antithrombotic treatment. Because of the absence of foreign material inside the heart, epicardial appendage closure possibly does not necessitate antithrombotic therapy, but data of large series are missing. Methods: Multidisciplinary team evaluation for standalone totally thoracoscopic epicardial appendage closure was done in 180 consecutive patients with atrial fibrillation and poor tolerance to antithrombotic therapy. One hundred and fifty-two patients consented (male 66.1%, mean age 76.1 ± 7.4, CHA2DS2VASc mean 5.3 ± 1.6, HASBLED mean 3.8 ± 1.1). Indications were cerebral hemorrhage (48%), gastro-intestinal bleeding (33.3%), and other bleeding (20.7%). No antithrombotic therapy was prescribed from the day of surgery to the latest follow up. Results: Procedural success was 98.7%. At a mean follow up of 38.2 ± 18.8 months, cardioembolic and bleeding events were 1.3% and 0.6%, respectively. Among patients with a history of blood transfusions (41.1%), none needed further transfusions or treatment post procedure. Conclusion: Epicardial appendage occlusion without any antithrombotic therapy appears to be safe and effective. This strategy could be advised when minimization of bleeding risk concomitant to stroke prevention is needed.

Heart Team for Left Appendage Occlusion without the Use of Antithrombotic Therapy: The Epicardial Perspective

BACKGROUND

Left atrial appendage occlusion is an increasingly proposed treatment for patients with atrial fibrillation and poor tolerance to anticoagulants. All endovascular devices require antithrombotic therapy. Anatomical and clinical variables predisposing to device-related thrombosis, as well as post-procedural peri-device leaks, could mandate the continuation or reintroduction of aggressive antithrombotic treatment. Because of the absence of foreign material inside the heart, epicardial appendage closure possibly does not necessitate antithrombotic therapy, but data of large series are missing.

METHODS

Multidisciplinary team evaluation for standalone totally thoracoscopic epicardial appendage closure was done in 180 consecutive patients with atrial fibrillation and poor tolerance to antithrombotic therapy. One hundred and fifty-two patients consented (male 66.1%, mean age 76.1 ± 7.4, CHA2DS2VASc mean 5.3 ± 1.6, HASBLED mean 3.8 ± 1.1). Indications were cerebral hemorrhage (48%), gastro-intestinal bleeding (33.3%), and other bleeding (20.7%). No antithrombotic therapy was prescribed from the day of surgery to the latest follow up.

RESULTS

Procedural success was 98.7%. At a mean follow up of 38.2 ± 18.8 months, cardioembolic and bleeding events were 1.3% and 0.6%, respectively. Among patients with a history of blood transfusions (41.1%), none needed further transfusions or treatment post procedure.

CONCLUSION

Epicardial appendage occlusion without any antithrombotic therapy appears to be safe and effective. This strategy could be advised when minimization of bleeding risk concomitant to stroke prevention is needed.

Rebleeding after hemoclip versus argon plasma coagulation for gastrointestinal angiodysplasias: a retrospective multicenter study

BACKGROUND

Hemoclips are utilized for treating bleeding gastrointestinal angiodysplastic lesions (GIADs); however, the supporting evidence is limited.

AIMS

Our aim is to evaluate the efficacy of hemoclips in preventing bleeding secondary to GIADs compared to argon plasma coagulation (APC).

METHODS

This retrospective study included patients with bleeding gastric, small bowel or colonic GIADs that were endoscopically treated between January 2009 and November 2016. Patients that received hemoclips as monotherapy or in combination were compared to a randomly selected similar number of patients treated with APC.

RESULTS

We included 157 patients that underwent APC and 141 who received hemoclips. During a median follow-up of 17 months, those with hemoclips had a 32.6% rebleeding vs. 46.5% in the APC group (P = 0.017). On multivariate regression analysis, use of hemoclips was not a significant predictor of rebleeding when compared to APC; hemoclips monotherapy (HR, 0.92; 95% CI, 0.54-1.59) and hemoclips combination (HR, 0.65; 95% CI, 0.41-1.01). When the multivariate analysis was restricted to subjects that resumed antithrombotics after endoscopy, rebleeding risk was lower when hemoclips were used in combination (HR, 0.46; 95% CI, 0.25-0.84) compared to APC. We noted a similar effect in the antithrombotic subgroup even after propensity score matching (HR, 0.51; 95% CI, 0.27-0.95).

CONCLUSION

Treatment modality was not a significant predictor of rebleeding when studied for the entire population. However, the risk of rebleeding was lower with hemoclips combination therapy compared to APC in patients that resumed antithrombotic therapy, suggesting a potential role for a combined approach in this subgroup of patients.

Evaluation and Validation of a New Score to Measure the Severity of Small Bowel Angiodysplasia on Video Capsule Endoscopy

INTRODUCTION

Angiodysplasias are responsible of 50% of small bowel bleeding. An endoscopic method that allows measuring its severity is not available.

AIMS

The aim of the study was to validate a new endoscopic score with VCE to measure the severity of small bowel angiodysplasias (SBAD).

METHODS

Four endoscopists independently reviewed VCE videos of 22 patients with SBAD. The score graded 3 variables: A - extent of lesions: E1, located in one half of the intestine and E2, in both halves; B - number of lesions: N1, <5; N2, 5-10; and N3, >10 lesions; C - probability of bleeding: P1, pale red spots; P2, bright red spots; P3, bleeding stigmata; and P4, active bleeding. Capsule Endoscopy Small Bowel Angiodysplasia Activity Index (CESBAI) was calculated as follows: E × 1 + N × 2 + P × 3. Interobserver variability was analyzed by Spearman's correlation and agreement Kappa statistic tests.

RESULTS

The mean CESBAI scores by observers were O1= 11.6 ± 4.1; O2 = 11.3 ± 4.8; O3 = 11.1 ± 4.9; and O4 = 11.8 ± 4.2 (p > 0.05). Spearman's correlation values of CESBAI between every 2 observers were from 0.61 to 0.94 (p < 0.001) with a global correlation of 0.73 among all observers. Kappa values of CESBAI between every 2 observers ranged from 0.42 to 0.87 (p < 0.001) with a global agreement of 0.57 among all observers. All evaluators stated that the method was easy to use.

CONCLUSIONS

CESBAI is a reliable and reproducible score. Nevertheless, these results must be validated in other studies with larger population before assessing its power for predicting bleeding recurrence.

Comparison of Argon Plasma Coagulation and Injection Therapy with Adrenalin and Polidocanol in the Management of Bleeding Angiodysplasia in Upper Gastrointestinal Tract

INTRODUCTION

The term angiodysplasia (AD) refers to acquired malformation of the blood vessels (communications between veins and capillaries), frequently found within the gastrointestinal mucosa and submucosa. AD of stomach and duodenum are cause of upper gastrointestinal bleeding in 4%-7% of patients. The means of treatment are usually endoscopic, including argon plasma coagulation (APC), electrocoagulation, mechanical hemostasis by clippsing, laser photo-coagulation and injection therapy.

AIM

To compare the success rate, and adverse events (ulcer lesions, perforations) of APC and injection therapy in the treatment of bleeding angiodysplasia in the upper gastrointestinal tract (GIT).

MATERIAL AND METHODS

In a prospective study including 50 patients with bleeding angiodysplasia of the upper GIT, 35 patients were treated with APC, and remaining 15 with injection therapy using adrenaline and 1.5% solution of polidocanol. Follow-up period was 6 months.

RESULTS

A total of 50 patients aged 18 to 64 years, 64% male and 36% female, have been treated during 2 years period. The rate of recurrent bleeding and side effects was significantly higher in the adrenaline group (p <0.01). Blood transfusion was required in 68% during the first hospital admission. Angiodysplasia of the stomach was present in 66%, versus 34% in duodenum.

CONCLUSION

Endoscopy is "gold standard" for diagnosis and treatment of AD in the gastrointestinal tract. The study unveiled APC as more effective treatment option with lower degree of complications and adverse events in comparison to injection therapy in patients with bleeding AD.

A Risk Assessment of Factors for the Presence of Angiodysplasias During Endoscopy and Factors Contributing to Symptomatic Bleeding and Rebleeds

BACKGROUND

Few studies have assessed factors associated with angiodysplasias during endoscopy or factors associated with symptomatic disease.

AIMS

To evaluate risk factors for the presence of and contribution to symptomatic disease in patients with angiodysplasias.

METHODS

We performed a systematic MEDLINE, EMBASE and Cochrane Library search according to the PRISMA guidelines for studies assessing risk factors involved in angiodysplasias detected during endoscopy and factors that lead to anemia or overt bleeding. Study quality was assessed with the Newcastle-Ottawa scale. A risk assessment was performed by selecting risk factors identified by two independent studies and/or by a large effect size.

RESULTS

Twenty-three studies involving 92,634 participants were included. The overall quality of the evidence was moderate. Risk factors for the diagnosis of angiodysplasias during endoscopy confirmed by at least two studies were increasing age (OR 1.09 per year, 95% CI 1.04-1.1), chronic kidney disease (OR 4.5, 95% CI 1.9-10.5) and cardiovascular disease (2.9, 95% CI 1.4-6.2). The risk of rebleeds was higher in the presence of multiple lesions (OR 4.2, 95% CI 1.1-16.2 and 3.8, 95% CI 1.3-11.3 and 8.6, 95% CI 1.4-52.6), liver cirrhosis (OR 4.0, 95% 1.1-15.0) and prothrombin time < 30% (OR 4.2, 95% 1.1-15.4) with a moderate effect size. Multiple comorbidities were associated with an increased in-hospital mortality (OR 2.29, 95% CI 1.2-4.3).

CONCLUSIONS

This systematic review identified age, chronic kidney disease and cardiovascular disease as the most important risk factors for the diagnosis of angiodysplasias during endoscopy. Multiple lesions increase the risk of recurrent bleeding.

Prevention of Recurrent Lower Gastrointestinal Hemorrhage

This article summarizes current knowledge regarding the incidence of and risk factors associated with recurrent lower gastrointestinal hemorrhage. The literature regarding medical, endoscopic, and surgical methods to prevent rebleeding from diverticulosis, angioectasia, and chronic hemorrhagic radiation proctopathy is reviewed. In addition, the evidence for endoscopic clipping as primary prophylaxis against postpolypectomy bleeding is explored.

Lanreotide in the management of small bowel angioectasias: seven-year data from a tertiary centre

BACKGROUND AND AIMS

Haemorrhage from small bowel angioectasias (SBAs) can be debilitating to patients who are very often elderly and have multiple comorbidities. Our aim was to assess the use of lanreotide in addition to endotherapy in patients with SBAs.

METHOD

Patients with SBAs on capsule endoscopy (CE) who received lanreotide injections from January 2010 to till the present day at the Royal Hallamshire Hospital in Sheffield were included. Baseline demographics were recorded. Efficacy was evaluated in terms of improvement in mean haemoglobin, transfusion requirements and bleeding episodes.

RESULTS

Twelve patients (67% males, mean age 74 SD ± 15.5 years) were included. All patients had multiple comorbidities. Lanreotide was given at a dosage of 60 mg (42%), 90 mg (33%) or 120 mg (25%). It was given at a four-week interval in 75% of patients and at a six-week interval in 17% of patients. One patient (8%) received a single dose. The mean duration of treatment was 19 months SD ± 14.5. Only 17% of patients had their lanreotide stopped due to cholelithiasis. There was a significant improvement in mean haemoglobin: 86.8 versus 98.0 (131-166 g/L, p = .012). The mean number of bleeding episodes (4.18 versus 1.09, p = .010) and packed red cells (323 versus 152, p = .006) received improved. Patients required less DBEs ± APCs after starting lanreotide (19 versus 11 p = .048).

CONCLUSION

Lanreotide is a useful adjuvant treatment to therapeutic enteroscopy in patients with refractory obscure gastrointestinal bleeding due to SBAs. It improves haemoglobin levels, reduces transfusion requirements, bleeding episodes and number of DBEs. Overall, it has a good safety profile.

Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation and Previous Major Gastrointestinal Bleeding (from the Amplatzer Cardiac Plug Multicenter Registry)

History of major gastrointestinal (GI) bleeding may represent a frequent clinical indication for left atrial appendage occlusion (LAAO) in patients with non-valvular atrial fibrillation (AF). This study aims to investigate the procedural safety and long-term outcome of patients with previous major GI bleeding (MGIB) who underwent LAAO. Data from the Amplatzer Cardiac Plug multicenter registry on 1,047 patients were analyzed. Patients with previous MGIB as indication for LAAO were compared with patients without previous MGIB. A total of 151 patients (14.4%) with previous MGIB were identified. Periprocedural major bleeding events were more frequent in patients with previous MGIB (4.0% vs 0.8%, p = 0.001). With an average follow-up of 1.3 years, the observed annual rate of stroke/transient ischemic attack and major bleeding for patients with previous MGIB were 2.1% (61.4% relative reduction according to the Congestive Heart failure, Hypertension, Age ≥75 (doubled), Diabetes, Stroke (doubled), Vascular disease, Age 65-74, and Sex (female) [CHA₂DS₂-VASc] score) and 4.6% (20.1% relative reduction according to the expected rate based on the Hypertension, Abnormal renal/liver function (1 point each), Stroke, Bleeding history or predisposition, Labile INR, Elderly (>65 years), Drugs/alcohol concomitantly (1 point each) [HAS-BLED] score), respectively. In conclusion, in patients with non-valvular atrial fibrillation and previous MGIB, LAAO was associated with a low annual rate of stroke/transient ischemic attack. Periprocedural major bleeding events were more frequent in this specific population although the annual major bleeding rate showed a 20.1% relative risk reduction according to the HAS-BLED score.

Review on gastrointestinal angiodysplasia throughout the gastrointestinal tract

Gastrointestinal angiodysplasia are rare but clinically important vascular aberrations found within the gastrointestinal mucosa and submucosa. Their clinical impact varies from being an asymptomatic incidental finding, to causing life threatening bleeding. In this review we critically appraise the key findings from the current literature on the pathology, clinical presentation and management of these lesions.

Gastrointestinal Angiodysplasia: Diagnosis and Management

Gastrointestinal angiodysplasia (GIAD) are red flat arborized lesions that are found throughout the entire gastrointestinal tract. GIAD can vary in size and have a range of presentation from occult to life-threatening bleeding. The typical presentation is intermittent bleeding in the setting of iron deficiency anemia. Endoscopy is the primary means of diagnosis and endoscopic therapy is noted to be initially effective. However, rebleeding can be as high as 40% to 50% in patients with small bowel GIAD. This review describes the pathophysiology for the development of GIAD and the current roles of endoscopic, medical, and surgical therapy in its treatment.

Evaluation of the efficacy of therapeutic endoscopy in gastrointestinal bleeding secondary to angiodysplasias

INTRODUCTION

Gastrointestinal angiodysplasias are defined as vascular dilations that communicate capillaries and veins in the walls of the digestive tract. The clinical presentation of these lesions varies from chronic occult bleeding to severe gastrointestinal hemorrhage.

AIM

The primary aim of our study was to analyze lesion location, the efficacy of therapeutic endoscopy with argon plasma coagulation, and the factors associated with rebleeding in patients with gastrointestinal angiodysplasias.

MATERIAL AND METHODS

A retrospective study of 32,042 endoscopies was carried out within the time frame of January 2012 and December 2013 at our hospital center. Gastrointestinal angiodysplasia was the diagnosis in 331 of the endoscopies. The procedures included upper gastrointestinal endoscopy, colonoscopy, sigmoidoscopy, and enteroscopy.

RESULTS

The most frequent location of the angiodysplasias was the cecum (49%), followed by the ascending colon (17%) and the sigmoid colon (16%). They were most frequently found in the duodenum (60%) and gastric body (49%) at upper gastrointestinal endoscopy. Therapeutic endoscopy was performed in 163 cases (49.8%) and the most predominant methods were fulguration with argon (90%) and combination treatment (argon plasma coagulation and injection sclerotherapy) (6.7%). The macroscopic rebleeding rate after therapeutic endoscopy was 7.4%. Patients that had rebleeding presented with a lower hemoglobin concentration, higher mean age, and the presence of multiple angiodysplasias at endoscopy (P<.05).

CONCLUSIONS

Therapeutic endoscopy was performed in 49.8% of the patients with angiodysplasias. The macroscopic rebleeding rate after treatment was 7.4%. There were statistically significant differences in the patients with rebleeding in relation to mean age, hemoglobin values, and the presence of multiple angiodysplasias.

Analysis of risk factor and clinical characteristics of angiodysplasia presenting as upper gastrointestinal bleeding

BACKGROUND/AIMS

Angiodysplasia is important in the differential diagnosis of upper gastrointestinal bleeding (UGIB), but the clinical features and outcomes associated with UGIB from angiodysplasia have not been characterized. We aimed to analyze the clinical characteristics and outcomes of angiodysplasia presented as UGIB.

METHODS

Between January 2004 and December 2013, a consecutive series of patients admitted with UGIB were retrospectively analyzed. Thirty-five patients with bleeding from angiodysplasia were enrolled. We compared them with an asymptomatic control group (incidental finding of angiodysplasia in health screening, n = 58) and bleeding control group (simultaneous finding of angiodysplasia and peptic ulcer bleeding, n = 28).

RESULTS

When patients with UGIB from angiodysplasia were compared with the asymptomatic control group, more frequent rates of nonantral location and large sized lesion (≥ 1 cm) were evident in multivariate analysis. When these patients were compared with the bleeding control group, they were older (mean age: 67.94 ± 9.16 years vs.55.07 ± 13.29 years, p = 0.03) and received less transfusions (p = 0.03). They also had more frequent rate of recurrence (40.0% vs. 20.7%, p = 0.02).

CONCLUSIONS

Non-antral location and large lesions (≥ 1 cm) could be risk factors of UGIB of angiodysplasia. UGIB due to angiodysplasia was more common in older patients. Transfusion requirement would be less and a tendency of clinical recurrence might be apparent.

Colonic Angiodysplasia with a Huge Submucosal Hematoma in the Sigmoid Colon

Colonic angiodysplasia (AD) with bleeding as a comorbidity in the aging population is being increasingly reported. However, to our knowledge, there is no report on colonic AD accompanied by a huge hematoma. Herein, we report a case of colonic AD with a huge submucosal hematoma. A 75-year-old man with sudden melena was referred to our hospital. Helical computed tomographic angiography (CTA) revealed bleeding from the sigmoid colon. Additionally, colonoscopy showed a huge submucosal hematoma with bleeding in the sigmoid colon. As endoscopic hemostasis was difficult, sigmoidectomy was performed. The pathological diagnosis was colonic AD. The present case indicates that colonic AD should be considered in the differential diagnosis for melena. In addition, the case shows that helical CTA, which is a noninvasive imaging modality, is useful for the diagnosis of colonic AD and is as effective as colonoscopy and angiography for diagnosis.

Medical and endoscopic therapies for angiodysplasia and gastric antral vascular ectasia: a systematic review

BACKGROUND & AIMS

Few studies have compared the efficacy and complications of endoscopic or medical therapies for bleeding angiodysplasias or gastric antral vascular ectasias (GAVE). We conducted a systematic review to evaluate therapies.

METHODS

We performed a PubMed search for studies (written in English from January 1, 1980, through January 1, 2013) of medical or endoscopic treatment of bleeding angiodysplasias and GAVE. Measured outcomes included levels of hemoglobin, transfusion requirements, rebleeding rates, complications, treatment failures, and overall mortality.

RESULTS

We analyzed data from 63 studies that met inclusion criteria; 50 evaluated endoscopic treatment (1790 patients), 13 evaluated medical treatment (392 patients), and 12 were comparative studies. In patients with angiodysplasias, the combination of estrogen and progesterone did not significantly reduce bleeding episodes, compared with placebo (0.7/y vs 0.9/y, respectively), and increased mortality, compared with conservative therapy (33% vs 21%). A higher percentage of patients receiving octreotide were free of rebleeding at 1 and 2 years vs placebo (77% vs 55% and 68% vs 36%, respectively; P = .03). Thalidomide reduced the number of bleeding episodes (-8.96/y), compared with iron therapy (-1.38/y, P < .01), but neither treatment reduced mortality. More patients with GAVE treated by endoscopic band ligation were free from rebleeding (92%) than those treated with argon plasma coagulation (32%, P = .01).

CONCLUSIONS

In a systematic review, we found a low quality of evidence to support treatment of angiodysplasias with thalidomide or the combination of estrogen and progesterone and insufficient evidence to support treatment with octreotide. There is also insufficient evidence for endoscopic therapy of angiodysplasia or GAVE. Well-designed randomized controlled trials are needed to study the efficacy and complications of medical and endoscopic treatments for patients with angiodysplasias or GAVE.

Management of gastrointestinal angiodysplastic lesions (GIADs): a systematic review and meta-analysis

OBJECTIVES

Gastrointestinal angiodysplastic lesions (GIADs) are defined as pathologically dilated communications between veins and capillaries. The objective of this systematic review and meta-analysis was to determine the efficacy of available treatment modalities for GIADs.

METHODS

We identified eligible studies by searching through PubMed, SCOPUS, and Cochrane central register of controlled trials. We searched for clinical trials examining the efficacy of endoscopic, pharmacologic, or surgical therapy for GIADs. Data were pooled using a random-effects model, and the effect of response to medical or surgical therapy was reported as odds ratios with 95% confidence intervals (CIs). Data and quality indicators were extracted by two authors from 22 studies, including 831 individuals with GIADs. The analysis included 623 patients treated with endoscopic therapy, 63 with hormonal therapy, 72 patients with octreotide, and 73 status post aortic valve replacement surgery.

RESULTS

Hormonal therapy, based on two case-control studies, was not effective for bleeding cessation (odds ratio: 1.0, 95% CI: 0.5-1.96). On the basis of 14 studies including patients with gastric, colonic, and small-bowel GIADs, endoscopic therapy was effective as initial therapy, but the pooled recurrence bleeding rate was 36% (95% CI: 28-44%) over a mean (±s.d.) of 22±13 months. The event rate for re-bleeding increased to 45% (95% CI: 37-52%) when studies including only small-bowel GIADs were included (N=341). In four studies assessing the efficacy of somatostatin analogs, the pooled odds ratio was 14.5 (95% CI: 5.9-36) for bleeding cessation. In two studies assessing the role of aortic valve replacement (AVR) in 73 patients with Heyde's syndrome, the event rate for re-bleeding was 0.19 (95% CI: 0.11-0.30) over a mean follow-up period of 4 years postoperatively.

CONCLUSIONS

Over one-third of patients with GIADs experienced re-bleeding after endoscopic therapy. Somatostatin analogs and AVR for Heyde's syndrome appeared to be effective therapy for GIADs.

An update and current expert opinions on percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation

Oral anticoagulation (OAC) remains the mainstream therapy for ischaemic stroke prevention in patients with atrial fibrillation (AF). However, for patients contraindicated to OAC and those who experienced a stroke while on therapeutic OAC, no reasonable pharmacotherapy is available. Although surgical left atrial appendage (LAA) excision offers a non-pharmacological alternative, effective stroke prevention by this treatment is not demonstrated by randomized clinical studies. Percutaneous occlusion of the LAA may be an alternative therapy for selected AF patients. Recently reported results confirm the technical feasibility of this technique and its effectiveness in preventing ischaemic stroke. With increasing operator experience, successful and event-free device implantation is achieved in typically 97% of the cases. Moreover, in non-randomized cohorts implanted with LAA occlusion devices, stroke rates are markedly reduced compared with rates predicted by risk stratification schemes such as CHADS2 and CHA2DS2-VASc. This paper summarizes recently published results from clinical studies on percutaneous LAA occlusion and current expert opinions with respect to patients who may be suitable for this therapy. In addition, several aspects regarding the safety of device implantation for LAA occlusion and follow-up of patients are discussed.

Atrial Fibrillation - A Common Ground for Neurology and Cardiology

Atrial fibrillation (AF) has a huge impact on clinical stroke because it is the primary cause of cardio-embolism, which constitutes ~20% of all strokes. As a result, there is a great need to explore safer and more effective primary and secondary prophylactic agents. In this article, we discuss the overlapping issues pertaining to AF from both a neurology and cardiology standpoint. We focus on the dynamic interplay of neurovascular and cardiovascular diseases in relation to AF, traditional and novel risk factors for AF leading to stroke, impact of AF on cognitive decline, and current upstream medical and surgical options for embolism prophylaxis.

Is a repeat double balloon endoscopy in the same direction useful in patients with recurrent obscure gastrointestinal bleeding?

GOALS

To evaluate the usefulness of repeat double balloon endoscopy (DBE) in obscure gastrointestinal bleeding (OGIB).

BACKGROUND

OGIB recurs in 11% to 42% of patients after DBE. Little is known about the outcome of repeat DBE in recurrent OGIB after DBE.

STUDY

We reviewed clinical course of patients who underwent repeat DBE for recurrent OGIB in the same direction as in previous DBE. Diagnostic yield and therapeutic intervention of repeat DBE were analyzed.

RESULTS

Thirty-five repeat DBEs were performed in 32 patients (M:F=15:17; age range, 36 to 85 y). The first DBE identified a probable bleeding source in 21 (65.6%) patients. Angiodysplasia was the most common and was found in 16 patients. The second DBEs were performed after a median of 30 weeks (range, 1 to 204 wk). Oral approach only was performed in 28 patients and anal approach only in 4. Probable bleeding sources were detected in 17 (53.1%) patients. Sixteen (94.1%) cases were angiodysplasia, of which 14 patients had angiodysplasia also at the first DBE. All detected bleeding sources were managed with endoscopic interventions such as argon plasma coagulation. Seventeen of 21 patients with positive first DBE showed bleeding source at the repeat DBE, whereas none of the 11 patients with negative first DBE did (81.0% vs. 0%; P<0.001). Three patients underwent the third DBE. Angiodysplasias were detected in 2 patients (66.7%).

CONCLUSIONS

Repeat DBE in the same direction may detect bleeding sources in 53% of recurrent OGIB patients. The probability of bleeding source detection in repeat DBE is higher in patients with a prior positive DBE.

Frequency of rebleeding events in obscure gastrointestinal bleeding with negative capsule endoscopy

BACKGROUND AND AIMS

Although capsule endoscopy (CE) is widely used as a first-line diagnostic modality for obscure gastrointestinal bleeding (OGIB), the rebleeding rate after negative CE varies according to different studies. We tried to elucidate the outcomes after negative CE for OGIB and to determine the risk factors associated with rebleeding.

METHODS

We retrospectively reviewed data from 125 patients who had received CE for OGIB.

RESULTS

PillCam SB capsules were used for 92 patients (73.6%) and SB2 capsules for the other 33 (26.4%). The complete visualization of the small bowel was achieved in 93 patients (74.4%). Of the 63 patients (50.4%) who showed negative CE results, 60 patients did not receive any further specific treatment for OGIB, and were analyzed for the rebleeding rate and risk factors for rebleeding. Of the 60 patients, rebleeding episodes were observed in 16 patients (26.7%), and the cumulative rebleeding rates after 6, 12, 24, and 36 months were 12.4%, 14.3%, 28.7%, and 35.9%, respectively. Substantial rebleeding events were observed with similar frequency both after negative CE without subsequent treatment (26.7%) and after positive CE without specific treatment (21.2%) (P = 0.496).

CONCLUSIONS

Considerable rebleeding episodes were observed after negative CE result for OGIB. Further complementary diagnostic work-ups and close follow-up are needed to be considered for patients with OGIB and negative CE results.

Comparison of argon plasma coagulation in management of upper gastrointestinal angiodysplasia and gastric antral vascular ectasia hemorrhage

BACKGROUND

Vascular ectasias, including gastric antral vascular ectasia (GAVE) and angiodysplasia, are increasingly recognized as important sources of gastrointestinal bleeding. This study investigated and compared the efficacies and outcomes of treatment of upper gastrointestinal (UGI) angiodysplasia and GAVE hemorrhage by endoscopic argon plasma coagulation (APC).

METHODS

From January 2006 to December 2009, 46 patients diagnosed with upper GI bleeding caused by angiodysplasia or GAVE at a tertiary hospital were recruited into this study. They included 26 males and 20 females with an average age of 65.6 years (range, 45-90 years). All patients underwent APC for hemostasis during an endoscopic procedure. Parameters such as underlying co-morbidities, number of endoscopic treatment sessions, recurrent bleeding, and clinical outcomes during follow-up were analyzed.

RESULTS

The 46 patients with UGI vascular ectasia hemorrhage included 27 patients with angiodysplasia and 19 with GAVE. The patients with angiodysplasia were older than those with GAVE (71.6 ± 10.2 years versus 61.8 ± 11.9 years, P = 0.005). More GAVE patients than angiodysplasia patients had co-existing liver cirrhosis (63.2% versus 25.9%, P = 0.012). The patients with GAVE had a higher rate of recurrent bleeding (78.9% versus 7.4%, P < 0.001) and required more treatment sessions to achieve complete hemostasis (2.4 ± 1.4 versus 1.1 ± 0.1, P < 0.001) than those with angiodysplasia. Univariate analysis demonstrated that age greater than 60 years (odds ratio (OR) = 8.929, P = 0.003), GAVE (OR = 0.021, P < 0.001), and previous radiation therapy (OR = 11.667, P = 0.032) were associated with higher rates of recurrent bleeding. Further multivariate analysis revealed that GAVE was the only independent risk factor for recurrent bleeding after APC treatment (OR = 0.027, P < 0.001).

CONCLUSION

Endoscopic hemostasis with APC is a safe treatment modality for both angiodysplasia and vascular ectasia bleeding. The efficacy of APC treatment is greater for angiodysplasia than for vascular ectasia bleeding. GAVE patients have a higher recurrent bleeding rate and may require multiple treatment sessions for sustained hemostasis.

Do clinical characteristics predict the presence of small bowel angioectasias on capsule endoscopy?

BACKGROUND AND AIMS

Angioectasias (AVMs) are the most common vascular anomaly of the gastrointestinal (GI) tract, and these lesions are often associated with obscure gastrointestinal bleeding (OGIB). It is unknown if the presence of upper and/or lower gastrointestinal AVMs are predictive of small bowel AVMs. The aims of this study are to define the small bowel segmental distribution of AVMs and to identify the factors predicting the presence of small bowel AVMs among a cohort of patients with a known history of AVMs in the upper and/or lower GI tracts who are undergoing capsule endoscopy (CE) for OGIB.

METHODS

We performed a retrospective cohort analysis of 1,125 patients undergoing CE at our institution between 11/1/2001 and 8/31/2007. Inclusion criteria were: (1) complete esophagoduodenoscopy (EGD), CE, and colonoscopy, (2) OGIB indication for CE, and (3) history of ≥ 1 AVM on EGD and/or colonoscopy that was previously treated in the past or deemed not to be a clinically significant source of bleeding. Exclusion criteria were: (1) history of radiation therapy to the GI tract, and (2) presence of a congenital or systemic disease associated with GI AVMs. Data were extracted on: (1) age; (2) gender; (3) presence of diabetes, (4) presence of hypertension, (5) presence of aortic stenosis, (6) history of non-steroidal anti-inflammatory therapy, (7) history of anticoagulant therapy, (8) hemoglobin, platelet, and INR values prior to CE; (9) baseline serum creatinine; and (10) presence and GI tract segmental location of AVMs. Multivariate logistic regression was used to identify independent predictors of small bowel AVMs.

RESULTS

1,125 patients underwent EGD, CE, and colonoscopy. One hundred and fourteen patients had a history of ≥ 1 AVM on EGD and/or colonoscopy and met inclusion and exclusion criteria. The mean age was 69 years, and 63% of patients were women. 37% of patients were found to have ≥ 1 jejunal AVM and 15% were found to have ≥ 1 ileal AVM. In multivariate analysis, age ≥ 65 (OR 2.62, P = 0.05) and the presence of AVMs on EGD (OR 4.61, P = 0.02) were predictive of jejunal AVMs. AVMs on colonoscopy alone were not predictive of jejunal or ileal AVMs. No factors were found to predict the presence of ileal AVMs.

CONCLUSIONS

Patients with AVMs on EGD have an increased risk of jejunal AVMs on CE, particularly if they are elderly. Future studies should validate these findings in a prospective cohort.